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All Journal Miracle Get Journal Science Get Journal Journal of Health Service Administration and Hospital Management Research and Evidence on Knowledge in Administration and Management — Medical Electronic Data and Information Systems
Mila Sari
STIKES Dharma Landbouw, Indonesia
Biochemistry, Genetics & Molecular Biology Chemistry Health Professions Mathematics Physics Public Health

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Factors Associated with Incomplete Informed Consent in Inpatient Medical Records Rudy Dwi Laksono; Mila Sari
Research and Evidence on Knowledge in Administration and Management — Medical Electronic Data and Information Systems Vol. 2 No. 1 (2026): March, 2026
Publisher : CV. Get Press Indonesia

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.69855/rekammedis.v2i1.636

Abstract

Informed consent is a crucial component of medical records that serves as legal evidence and a means of protecting patient rights; however, incomplete documentation remains a common issue that may compromise healthcare quality. This study aimed to analyze factors associated with incomplete informed consent documentation in inpatient medical records. A quantitative study with a cross-sectional design was conducted on 120 medical records selected using systematic random sampling. The dependent variable was the completeness of informed consent, while the independent variables included staff knowledge, years of experience, workload, and compliance with standard operating procedures (SOPs). Data were collected using a checklist based on Ministry of Health Regulation No. 290 of 2008 and analyzed using univariate and bivariate methods with the Chi-square test at a significance level of 0.05. The results showed that incomplete informed consent documentation was relatively high (62.5%). Bivariate analysis indicated that knowledge (p=0.002; OR=5.5), workload (p=0.004; OR=5.0), and SOP compliance (p=0.001; OR=7.55) were significantly associated with incomplete documentation, while years of experience was not significantly associated (p=0.087). In conclusion, the incompleteness of informed consent is influenced by both individual and system-related factors, with SOP compliance identified as the most dominant factor.
Analysis of the Implementation of Medical Record Retention Based on Medical Record Officers' Perceptions: A Qualitative Case Study at Siti Rahmah Islamic Hospital Padang Yulfa Yulia; Mila Sari; Arif Prima
Research and Evidence on Knowledge in Administration and Management — Medical Electronic Data and Information Systems Vol. 2 No. 1 (2026): March, 2026
Publisher : CV. Get Press Indonesia

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.69855/rekammedis.v2i1.706

Abstract

The implementation of medical record retention is an important activity in medical record management to ensure storage efficiency, ease of file retrieval, and compliance with applicable regulations. However, its implementation in hospitals still faces obstacles, such as limited human resources, storage facilities, and officers' understanding of retention procedures. This study aims to analyze the implementation of medical record retention based on the perceptions of medical record officers. Unlike previous studies that focused mainly on compliance with retention procedures, this study explores medical record officers' perceptions to identify organizational and operational barriers affecting retention implementation. This study employed a qualitative case study design at the Medical Record Installation of Siti Rahmah Islamic Hospital Padang involving five informants selected through purposive sampling. Data were collected through in-depth interviews, observations, and document analysis, and analyzed using the Miles and Huberman model. The findings indicate that retention procedures have been implemented but not consistently or according to schedule. The main barriers include varying levels of officers' understanding, limited facilities and storage space, and inadequate monitoring and evaluation. It was concluded that strengthening human resources, facilities, and supervision is essential to optimize medical record retention implementation.
Co-Authors Adriani Agnes Ratna Saputri Andrafikar Arif Prima Esa Zahirah Evino Sugriarta Rozlinda Dewi Rudy Dwi Laksono Safiyah Kamilah Samuel Hadjo Yulfa Yulia